STATEMENT

STATEMENT Thomas J. Magnani D.D.S. Alvin Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 Mr. Jeff Epstein 9 East 71st Street New York NY 10021 Telephone: It paying by cm. ant freer ar amount you am prim in Um manna Ho Gnu Moue Wray MostunnvO Ma Miex Cord* E,v Dae 591._I 54 code Data Account 7/1/2015 10055 Rernktance IMPORTANT • PLEASE DETACH UPPER PORTION AND RETURN YOH YOUR REMITTANCE TO INSURECW-01T TO PROPER ACCOUNT Date Patient Description Charges Credits Balance 6/3/2015 Previous Balance 0.00 6/16/2015 Sue Adult Scale & Prophy 180.00 180.00 6/16/2015 Sue Recall Oral Exam 40.00 220.00 6/16/2015 Sue Electric toothbrush 160.00 380.00 6/16/2015 Sue Laser Bleaching 750.00 1.130.00 Account Total 1,130.00 If payment has been sent, please disregard this statement -Thank You. We accept credit cards You may complete top part of this statement, or call the office aliiiiii. Current 30 Days 60 Days 90 Days 120+ Days 1,130.00 0.00 0.00 0.00 0.00 Thomas J. Mignon' D.D.S. /Win Grayson D.D.S. 7 West 51st Street 7th Floor New York NY 10019 EFTA01202237